伤寒论平脉法第十三节。问曰。脉有灾怪。何谓也。师曰。假令人病。脉得太阳。与形
证相应。因为作汤。比还送汤如食顷。病患乃大吐。若下利。腹中痛。师曰。我前来不见此
证。今乃变异。是名灾怪。问曰。何缘得此吐利。答曰。或有旧时服药。今乃发作。故为灾
怪耳。程郊倩注曰。望问固医家之事。亦须病家毫无隐讳。方能尽医家之长。因复出此条。
为病家服药瞒医之戒。灾因自作。而反怪及医。故曰灾怪。然更有怪灾病。不可不知。得仲
景法。处仲景方。病家大怪。以示诸医。益摇脑吐舌而大怪。乃从其不怪者治之。轻者剧。
重者死。而灾及其身。终不解其病谓何病。此病近日竟成疫。沿门渐染。仲景却未言及。想
仲景时只有灾怪病。尚无怪灾病耳。一噱。
按程郊倩谓怪灾病。孽不在庸医之好造谣言。而在病家之贵耳贱目。执俗本之本草。查
对名医之处方。执俗本之套语。贬驳名医之治法。以致名医叹息而不与辨。决然而去。岂非
灾由自取耶。忆戊辰春。
李太守名符清。患气短病。余主以桂苓甘术汤与肾气丸间服。许以半月必效。旋有所闻。
惊怪而阻。另延津门陶老医。服葶苈、杏仁、枇杷叶、木通之类三十余剂。胀肿癃闭而逝。
候补知县叶名钧。偶患咳嗽。微发热。小便不利。余曰。小青龙汤一服可效。渠怪而不服。
另
贝母之类为佐。二十余日后。与余相遇于北关官廨。自言咳嗽已愈。惟早起气觉短促。余无
他病。余察其面部皮里膜外伏青黯之色。圜口尤甚。按其脉数而弦芤。重按之散而无神。
直告之曰。此群阴用事。阳光欲熄之候。宜抛去前药。以白术、附子浓煎。调生姜自然汁半
杯。六七服。尚可急救。叶公以余言太激而不答。是晚自觉倦怠异常。前医仍用熟地一两。
党参五钱。枸杞、麦冬、阿胶各三钱。杜仲、酒芍、当归各二钱。炙甘草一钱。服之次早神
昏不语。痰涎如涌。渠胞弟惊告余曰。前言一线残阳。扶之尚恐不及。况以熟地等助其阴霾
之气乎。今阴霾之气。上弥天际。痰涎涌盛。状如中风。盖以肝为风木之脏。人当东方生气
将脱之顷。往往外呈此象。其证与中风无异也。诊其脉。弦数散乱。三五不调。余直辞不治。
次日未刻果殁。庚午秋七月。前任天津尹丁名攀龙。过余旅寓。见其面上皮里黧黑。环唇更
甚。
卧蚕微肿。鼻上带些青色。余直告之曰。君有水饮之病根。挟肝气而横行无忌。此时急
疗可愈。若迟至二十日。病一发作。恐医日多。方日杂。总不外气血痰郁四字。定出搔不着
痒之套方。即有谈及水饮。缓治以六君、二陈加减。峻治以滚痰、黑锡专方。此敷衍题面。
而题理题神则尽错矣。以药试病。试穷则变计。虽卢扁莫何。丁君心怪言之过激。弗听。至
七月下旬病作。中秋后渐重。九月下旬邀诊。余告之曰。向者所陈之弊。今一一蹈之。前说
明病发后毋庸用药。非自今推诿。
然无中生有之治法。惟金匮咳嗽篇用十枣汤。云。咳家其脉弦者。有水。此主之。又云
。支饮家咳烦胸中痛者。不卒死。至一百日或一岁。亦宜用此汤。推病根成于旧岁冬初。未
及一岁。且病发止六十余日。尚在百日之内。喻嘉言医门，法律咳嗽续论篇。言之甚详。俟
有识有胆者用之。而余则不能。坐中有一老医力争不可。余姑拟龙、牡、甘、苓行水化气等
药
附子、肉桂、人参。服之不断。渐至大喘。肿胀吐血。大衄。耳目俱出血。小水全无而殁。
此皆怪灾病之新案。
《伤寒论》平脉法第十三节。有人问道：脉象中有“灾怪”这一说法，是什么意思呢？老师回答说：假如一个人患病，脉象表现为太阳病（太阳经受邪所致的病证），且脉象与形体症状相符，于是医生为他开具汤药。等到送药回来，大约一顿饭的工夫，病人却突然发生剧烈呕吐，或者出现腹泻、腹痛等症状。老师说：“我先前诊察时并未见到这些症状，现在病情突然变异，这就叫做‘灾怪’。”又问道：“为什么会发生这种呕吐和腹泻呢？”回答说：“可能是因为病人以前服用过某些药物，到现在才发作，所以称为‘灾怪’。”
程郊倩注释说：望诊和问诊虽然是医生的职责，但也需要病人毫无隐瞒，这样才能发挥医生的全部才能。因此特意列出这一条，作为对病人瞒着医生服药的告诫。灾祸是自己造成的，反而责怪医生，所以称为“灾怪”。然而还有一种“怪灾病”，不可不知道。如果遵循张仲景的方法，使用张仲景的方剂，病人会感到非常奇怪，以此向各位医生展示，那些摇头吐舌、大惊小怪的医生，反而去治疗那些不奇怪的病症。轻则加重病情，重则导致死亡，灾祸降临到病人身上，始终不明白这到底是什么病。这种病在近日竟然成了瘟疫，挨家挨户逐渐传染。张仲景却没有提及，想来张仲景时代只有“灾怪病”，还没有“怪灾病”罢了。真是令人发笑。
按语：程郊倩所说的“怪灾病”，罪孽不在于庸医喜欢制造谣言，而在于病人重视耳闻而轻视亲眼所见，拿着通俗版本的《本草纲目》，去核对名医的处方；拿着通俗版本的套话，贬低驳斥名医的治疗方法，致使名医叹息而不愿辩解，决然离去。这难道不是灾祸自取吗？
回忆戊辰年春天，李太守名符清，患有气短病。我主张用桂苓甘术汤与肾气丸交替服用，承诺半个月必定见效。不久后他听信了别人的闲言碎语，感到惊怪而阻止服药，另外聘请了天津的陶老医生。服用了葶苈子、杏仁、枇杷叶、木通等药物三十多剂后，因腹胀水肿、小便闭塞不通而去世。
候补知县叶名钧，偶然患上咳嗽，伴有轻微发热，小便不利。我说：“服用一剂小青龙汤即可见效。”他感到奇怪而没有服用，另外请医生开了以贝母等为佐使的药物。二十多天后，我在北关官署遇见他，他说咳嗽已经痊愈，只是早起时觉得气短急促，没有其他疾病。我观察到他面部皮肤纹理间潜伏着青暗之色，口唇周围尤其严重。切按其脉搏数而弦芤，重按时散乱而无神。我直接告诉他：“这是群阴用事，阳光即将熄灭的征候。应当抛弃之前的药物，用白术、附子浓煎，调入生姜自然汁半杯，服用六七次，还可以急救。”叶公认为我的话太激进而没有回答。那天晚上他自觉异常疲倦，前医仍然使用熟地黄一两、党参五钱、枸杞、麦冬、阿胶各三钱、杜仲、酒白芍、当归各二钱、炙甘草一钱。服用后的第二天早上，病人神志昏迷不能说话，痰涎涌盛。他的胞弟惊恐地告诉我：“您之前说这是一线残阳，扶持它还怕来不及，何况用熟地黄等药物助长其阴霾之气呢？如今阴霾之气上冲天际，痰涎涌盛，状如中风。大概因为肝是风木之脏，人在东方生气将脱之际，往往外表呈现这种景象。此证与中风无异。”诊察其脉象，弦数散乱，三五不调。我直言不再治疗。第二天未时果然去世。
庚午年秋七月，前任天津知府丁名攀龙，经过我的旅舍。见他面部皮肤纹理间黧黑，嘴唇周围更甚，卧蚕部位微肿，鼻梁上带些青色。我直接告诉他：“您体内有水饮的病根，挟带肝气横行无忌。此时紧急治疗可以痊愈。如果拖延到二十天，病一旦发作，恐怕医生越来越多，方剂越来越杂乱，总不外乎气血痰郁这四个字，定出搔不着痒的套方。即使有谈及水饮的，缓治用六君子汤、二陈汤加减，峻治用滚痰丸、黑锡丹专方。这些都是敷衍题面，而题理题神则完全错了。以药物试探病情，试探穷尽则改变计划，即使是扁鹊也无法奈何。”丁君心里觉得我说得太激进，没有听从。到了七月下旬病发，中秋后逐渐加重，九月下旬邀请我去诊治。我告诉他说：“之前陈述的弊端，如今一一都犯了。之前的说法是病发后无需用药，并非从今日起推诿。然而无中生有的治疗方法，只有在《金匮要略》咳嗽篇中用到十枣汤时说：‘咳嗽的病人，脉象弦的，是有水饮，用此方主治。’又说：‘支饮病人咳嗽烦闷胸中痛的，如果不猝死，到一百天或一年，也适宜用此汤。’推断病根形成于去年冬天初，未满一年，且病发仅六十多天，还在百日之内。喻嘉言在《医门法律·咳嗽续论篇》中讲得很详细。等待有见识有胆量的人使用它，而我则不敢。座中有一位老医生极力争辩说不行。我姑且拟定了龙骨、牡蛎、甘草、茯苓等行水化气的药物，加上附子、肉桂、人参。病人不断服用，逐渐发展到严重喘息、肿胀、吐血、大出血，耳目都出血，小便全无而去世。这都是怪灾病的新案例。”
Chapter 13 of the Ping Mai Fa (Method of Assessing Pulse) in the Shang Han Lun. A question was asked: What is meant by "Zai Guai" (Disaster and Wonder/Monster) in pulse diagnosis? The Master replied: Suppose a person is ill, and the pulse indicates Tai Yang disease (a syndrome caused by pathogenic invasion of the Tai Yang channel), which corresponds with the physical signs and symptoms. Consequently, a decoction is prescribed. However, upon returning home to take the medicine, after about the time it takes to eat a meal, the patient suddenly experiences severe vomiting, or diarrhea accompanied by abdominal pain. The Master said: "I did not observe these symptoms during my initial examination; the condition has now changed abruptly. This is called 'Zai Guai'." Another question was raised: "What causes such vomiting and diarrhea?" The answer was: "It may be due to medication taken previously by the patient, which is only now taking effect. Hence, it is termed 'Zai Guai'."
Cheng Jiaoqian commented: Observation and inquiry are indeed duties of the physician, but they require the patient to be completely candid without concealment, so as to fully utilize the physician's expertise. Therefore, this clause is added as a warning against patients concealing their prior medication from doctors. The disaster stems from one's own actions, yet blame is shifted to the physician, hence the term "Zai Guai". However, there exists another type of illness known as "Guai Zai Bing" (Monster Disaster Disease), which must not be overlooked. If one follows the methods of Zhang Zhongjing and prescribes his formulas, the patient may find it strange and use this to demonstrate to other physicians. Those who shake their heads and stick out their tongues in exaggerated surprise will instead treat illnesses that do not present such strange features. Mild cases become severe, severe cases lead to death, and disaster befalls the body, leaving them unable to identify the nature of the disease. In recent times, such diseases have become epidemics, spreading house to house. Zhang Zhongjing did not mention this; perhaps in his era, there were only "Zai Guai Bing" but no "Guai Zai Bing". It is quite amusing.
In an annotation: Cheng Jiaoqian stated that for "Guai Zai Bing", the fault does not lie with quack doctors spreading rumors, but with patients valuing hearsay over direct observation. They consult popular versions of Ben Cao Gang Mu (Compendium of Materia Medica) to check prescriptions of famous doctors, and use clichés from common texts to criticize and refute the treatment methods of renowned physicians. This causes famous doctors to sigh and refuse to argue, leaving decisively. Is this not disaster brought upon oneself?
Recalling the spring of the Wuchen year, Li Taishou, named Fuqing, suffered from shortness of breath. I recommended alternating Gui Ling Gan Zhu Tang (Cinnamon Twig, Poria, Licorice, and Atractylodes Macrocephala Decoction) with Shen Qi Wan (Kidney Qi Pill), promising efficacy within half a month. Soon, he heard rumors, was startled and suspicious, and stopped taking the medicine. He hired an old doctor, Lao Tao, from Tianjin. After taking more than thirty doses of Ting Li Zi (Descurainiae Semen), Xing Ren (Armeniacae Semen), Pi Pa Ye (Loquat Leaf), and Mu Tong (Akebiae Caulis), among others, he died due to abdominal distension, edema, and urinary retention.
Ye Mingjun, a waiting magistrate, accidentally contracted cough with slight fever and difficulty urinating. I stated that one dose of Xiao Qing Long Tang (Minor Green Dragon Decoction) would yield results. He found this strange and refused to take it, instead consulting another doctor who prescribed herbs such as Bei Mu (Fritillariae Bulbus) as adjuvants. More than twenty days later, we met at the official residence in Beiguan. He said his cough had healed, but he felt short of breath early in the morning, with no other ailments. I observed a latent bluish-dark discoloration in the skin and subcutaneous tissue of his face, particularly around the mouth. Palpating his pulse, it was rapid, wiry, and hollow (Kou); upon heavy pressure, it was scattered and lacked spirit. I told him directly: "This is a sign of Yin pathogens prevailing and Yang light about to extinguish. You should discard previous medications. Boil Bai Zhu (Atractylodis Macrocephalae Rhizoma) and Fu Zi (Aconiti Lateralis Radix Preparata) strongly, mix with half a cup of fresh Ginger Juice (Sheng Jiang Zhi), and take six to seven doses. Emergency rescue is still possible." Lord Ye did not respond, considering my words too radical. That night, he felt exceptionally fatigued. The previous doctor continued prescribing Shu Di Huang (Rehmanniae Radix Preparata) 1 liang, Dang Shen (Codonopsis Radix) 5 qian, Gou Qi Zi (Lycii Fructus), Mai Dong (Ophiopogonis Radix), and E Jiao (Asini Corii Colla) each 3 qian, Du Zhong (Eucommiae Cortex), Jiu Shao Yao (Paeoniae Radix Alba preparata with wine), and Dang Gui (Angelicae Sinensis Radix) each 2 qian, and Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma Preparata) 1 qian. The next morning after ingestion, the patient fell into coma, unable to speak, with surging phlegm and saliva. His brother informed me in alarm: "You previously mentioned a wisp of residual Yang; supporting it might barely suffice, let alone using Shu Di Huang etc. to aid its Yin-damp energy. Now, Yin-damp energy fills the sky, phlegm surges, resembling Stroke (Zhong Feng). Since the Liver is the organ of Wind-Wood, when the vital Qi of the East is about to collapse, such external manifestations often appear. This syndrome is indistinguishable from Stroke." Palpating his pulse, it was wiry, rapid, scattered, irregular, and inconsistent. I explicitly stated I would not treat further. Indeed, he passed away at Wei hour the next day.
In the autumn of the Gengwu year, July, Ding Mingpanlong, former Prefect of Tianjin, visited my lodging. I saw dark black discoloration in his facial skin and subcutaneous tissue, especially around the lips. The area under the eyes (Wocan) was slightly swollen, and there was a hint of bluish color on the nose. I told him directly: "You have a root cause of Water-Drink pathology, carrying Liver Qi to act recklessly. Urgent treatment now can cure it. If delayed by twenty days, once the disease erupts, doctors will multiply, and prescriptions will become chaotic. It will all revolve around Qi, Blood, Phlegm, and Stagnation, resulting in ineffective standard formulas. Even if Water-Drink is discussed, mild treatment uses Liu Jun Zi Tang (Six Gentlemen Decoction) or Er Chen Tang (Two Aged Substances Decoction) modifications; severe treatment uses Gun Tan Wan (Rolling Phlegm Pill) or Hei Xi Dan (Black Tin Pill). These are perfunctory approaches, missing the essence of the case. Testing drugs on the disease until exhausted leads to changing strategies; even Bian Que could not help. Lord Ding thought my words were too extreme and did not listen. By late July, the disease erupted. After Mid-Autumn Festival, it worsened. In late September, he invited me to diagnose. I told him: "The faults I previously described have now occurred one by one. My earlier statement that no medication is needed after onset was not an excuse. However, creating treatments out of nothing, the only instance in the Cough Chapter of Jin Gui Yao Lue (Essential Prescriptions from the Golden Cabinet) using Shi Zao Tang (Ten Jujubes Decoction) states: 'For patients with cough and wiry pulse, indicating water retention, this formula is indicated.' It also says: 'For patients with Branch-Drink suffering cough, irritability, and chest pain, if they do not die suddenly, even after 100 days or a year, this formula is suitable.' Inferring the root cause formed in early winter last year, less than a year has passed, and the current onset is only over 60 days, still within 100 days. Yu Jiayan detailed this in Yi Men Fa Lv (Medical Laws of the Medical Gate) - Cough Continuation Discussion. Wait for someone with insight and courage to use it; I cannot. An old doctor in the room strongly argued against it. I tentatively prescribed Long Gu (Fossilia Ossis Mastodi), Mu Li (Concha Ostreae), Gan Cao (Licorice), and Fu Ling (Poria) for draining water and transforming Qi, along with Fu Zi (Prepared Aconite Root), Rou Gui (Cinnamon Bark), and Ren Shen (Ginseng Root). The patient took them continuously, gradually developing severe panting, swelling, hematemesis, massive hemorrhage, bleeding from ears and eyes, complete anuria, and finally died. These are all new cases of Guai Zai Bing."